Denise Petrella, RN, CS, ANP, of Boston Health Care for the Homeless Program's (BHCHP) Street Team walks toward the homeless men wrapped in grey blankets and huddling on a bench in downtown Boston. As she approaches, a shivering bearded man calls out, "Deni, I want to go in; I'm ready to go in." Those words are music to the ears of the street team. It means a sick homeless person is ready to accept treatment. Bob, a long-term client of BHCHP, wants to be admitted to an inpatient detoxification program to give sobriety another try. Bob also gestures to the blanket-covered figure passed out on the adjacent bench. "You'd better check on John," he tells Petrella. "He's in really rough shape and I'm worried."

Since 1994, BHCHP's street team has delivered high-level medical and mental-health services directly to homeless people in the places where they gather or seek shelter—the streets, alleys, bridges, and sidewalks of Boston. The team goes out four days and one evening a week. What they bring with them ranges from help obtaining an identification card to an emergency hospital admission. On Call recently accompanied the street team on their rounds. Here's how the team spent their morning.

Providing service for clients with multiple morbidities

Petrella's morning begins as soon as she ascends from Park Street Station to Boston Common. A ruddy-faced man in layers of sweatshirts calls her name and asks for help. In the corner of a warm coffee shop where the team assembles, Petrella makes her latest offer of an admission to Barbara McInnis House—BHCHP's inpatient medical respite program—for a complete neurological work-up of his progressing symptoms. When he consents to the admission, she hails a taxi, alerts the McInnis House (MIH) staff, and promises to visit him soon.

Petrella has been an adult nurse practitioner at BHCHP for 15 years. She was the first NP to join the street team. Her primary role is assessment and triage, since so many conditions exceed the treatment she can provide in a single encounter. She also carries the medical and personal histories of dozens of clients in her memory and in her notebook. In addition to checking wounds, applying dressings, and measuring blood glucose levels, Petrella says relationship building is an important part of treating the people the team sees. "I find homeless people need respect, love, and kindness, not just conventional treatment," Petrella says. "Often, they have not been treated with dignity by healthcare providers, and it takes awhile to earn their trust."

Kendall Jones, LICSW, has been a psychiatric social worker with BHCHP for seven years. Jones explains that the purpose of the team is engagement with those suffering from the trimorbidity of substance abuse, mental illness, and active medical problems. They seek out the "unsheltered" or "rough riders" who find the tumult of shelters intolerable. Often, the unsheltered suffer from the most extreme mental and physical illnesses. Jones says that the first step of engagement can be just a smile when the team sees the person in his habitual location every week. When the person can sustain three to five minutes of conversation, a team member buys him a cup of coffee and chats about light subjects. Eventually, they work up to asking, "How about coming to detox?" The more advanced stages of engagement occur when the man can tell someone why he drinks. "The ultimate goal," says Jones, "is to get him connected to a system of medical and psychiatric care."

Often, that system is within BHCHP, which operates an extensive network of services and clinics in their headquarters at Jean Yawkey Place across from Boston Medical Center, as well as in clinics at shelters, soup kitchens, and hospitals. The team can refer people with HIV/AIDS–related illness to BHCHP's HIV clinic. Petrella can also admit patients to McInnis House or send them to an emergency department for hospital admission.

Finding the right treatment facilities for clients who need them

Back in the coffee shop, Petrella and Jones brief each other on client updates and issues of concern from the weekly team meeting. Then they head out into the cold, wind-driven rain to look for specific clients and to make the acquaintance of more homeless people. Street-team members traverse all of the popular tourist areas of Boston where the homeless gather. They also venture into the places where the most vulnerable seek refuge.

On this day, their first stop is the wide plaza in front of Borders. Several benches are still occupied by people who have been there since the night before. While Jones introduces himself to a young woman and her companion, Petrella asks Bob about his current symptoms and telephones the Andrew House Detox Center. For the first time in two weeks, Andrews House has an open bed at the same time Bob wants to be admitted. Bob recounts his painful history of decades of alcoholism and homelessness while at the same time recounting his interims of sobriety and improved functioning like they are beacons of hope.

Petrella begins the long process of obtaining the seven medications Bob will need to bring with him to the detox program. Although he filled his prescriptions the week before, every medication was stolen while he slept in a subway entrance. Petrella negotiates with a nearby CVS pharmacy for a small supply of crucial medications for Bob's medical and psychiatric problems. Finally, she hands the full bag to a grateful Bob. As she tucks him into a taxi destined for detox, Bob promises he won't jump out at the next corner like he did last time. "I'm gonna do it right this time," he calls out.

As she tucks him into a taxi destined for detox, Bob promises he won't jump out at the next corner like he did last time. 'I'm gonna do it right this time,' he calls out.

She watches the taxi leave and then returns to assessing John, who lies face down and barely responsive on a bench as rain soaks his thin clothing and shoes. "I sent him to Mass General last week for a clostridium difficile infection and broken arm," she says, "but he signed himself out." Her assessment shows he is febrile, severely dehydrated, incontinent, and his fractured humerus is now dislocated. Within minutes, she has summoned an ambulance to bring John to the emergency department. Petrella calls in a report to Joseph Rampulla, MS, APRN, BC, a nurse practitioner based in the BHCHP's clinic at MGH, and asks him to check on John in the emergency room.

From pregnant women to returning vets with PTSD, matching care with needs

The street team encounters every type of medical and psychiatric illness. And often, illnesses have been made worse by the ravages of substance abuse and exposure to the extremes of weather. In the summer, asthma, heat stroke, and hyperthermia abound. In the winter, the team's clients are plagued by frostbite, hypothermia, and respiratory infections. Manifestations of complex chronic diseases, communicable diseases, seizure disorders, and every type of infection happen year round. For that reason, BHCHP has published The Health Care of Homeless Persons: A Manual of Communicable Diseases & Common Problems in Shelters & on the Street, a valuable resource for all healthcare providers working with the homeless.

On the Borders plaza, two outreach workers from Pine Street Inn make their rounds and offer shelter and services. They exchange information on clients they all know, and Petrella reminds them that they can page her if they find a person who needs medical attention. Outreach providers from several organizations collaborate to improve access to treatment for the homeless. A physician from BHCHP provides care on the Pine Street Inn overnight rescue van.

There are many women among the street dwellers, and Petrella worries about the young pregnant women she follows. Fortunately, she can admit those who are nearing their delivery date to Barbara McInnis House for prenatal care and a safe delivery. Jones says a newer phenomenon is the number of brutal assaults perpetrated by the homeless against each other. The older men attribute the assaults to an influx of transient younger men. Last week, Petrella treated a man who had been beaten with a wrench for sitting in another man's space. Another change is the number of Iraq War veterans—many suffering from post-traumatic stress disorder and substance abuse—who are living on the streets.

Jones and Petrella make their way through Government Center en route to MGH to check on John. If he is not admitted, Petrella will arrange for him to be transferred to McInnis House. On the way, they scan the alleys and plazas looking for Harry, a man who is due to be admitted to McInnis House in preparation for knee replacement surgery. Petrella explains, "We can get him through a safe detox, do all the pre-op testing, feed him well, and have him in better shape to recover from surgery."

They scan the alleys and plazas looking for Harry, a man who is due to be admitted to McInnis House in preparation for knee replacement surgery. Petrella explains, 'We can get him through a safe detox, do all the pre-op testing, feed him well, and have him in better shape to recover from surgery.'

The alleys are empty because the nearby shelters and soup kitchens have opened early to provide a refuge from the ceaseless rain. When Petrella and Jones arrive at the MGH emergency department, they meet with Rampulla and hear that John will be admitted. Then they take the opportunity to catch up with other clients who are receiving care at the street clinic Rampulla runs at MGH.

What it takes to provide the needed care: Clinical skills, teamwork, flexibility, and understanding

Jones and Petrella review their notes on each client they've seen today. When they return to BHCHP headquarters, they'll add their notes on each client to the electronic medical record. Petrella says, "We had three good encounters today, and laid the groundwork with a few new people. All in all, a good day."

In addition to astute clinical skills, there are other qualities that a clinician needs to work with the street team. Jones says one needs a combination of being grounded in the principles of any good system of care and the flexibility and judgment to apply those principles on the street. He adds that one has to know that, at the end of the day, a number count is not going to measure the work you've done. Some days, he spends the whole morning with two clients in crisis, and on other days, the team offers medical or safety checks to 25 homeless people. Teamwork is also critical. Street-team members rely on each other's receptivity to new information and ways of delivering care, as well as sharing the responsibility for staff safety in potentially dangerous situations.

Petrella believes professionals need to bring a completely open mind, nonjudgmental kindness, and extreme patience to their encounters. "Nothing happens overnight, changes are very slow," she says. The rapport, respect, and ease of connection Petrella and Jones have built up with their long-term clients is apparent throughout the morning as they alternate concerned questions and mutual banter. When a middle-aged man apologizes for the odor coming from his disheveled clothes, Petrella assures him, "I want you to know you are always kind, even when you're drinking. You are always a gentleman." He nods and says, "I try, but it's rough."

Petrella says that caring for the homeless can be very fulfilling when an approach works: "Sometimes it doesn't work, so the clients keep trying and so do we." Petrella and Jones share some of the success stories that keep them returning to their challenging work. A young woman with untreated schizophrenia accepted an admission to MIH where she received a life-changing trial of the right medications. When her illness stabilized, she was able to qualify for housing. They remember an older woman who had lived on the streets for 30 years. With medical care and a little medication, she is now comfortable in an assisted-living facility. They both emphasize that some people do give up alcohol or drugs, and often it's the person one least expects to stay sober who actually does.

Jones says that while working on the street team, stereotypes are challenged because they see clients in their living environment. He says, "The homeless are exactly like us—no more violent, crude, or crass than we are. They all come from brokenness, and in a way they all call out for healing."

Petrella adds that sometimes even healthcare professionals believe the homeless have made a conscious decision to be homeless, and therefore judge clients for the choices they've made. Petrella says, "It's a privilege to be there when they are ready to begin the process of recovery and healing. This work fulfills me professionally and spiritually."

Editor's note: This is the fourth and final article in an On Call series examining the issues around healthcare and homelessness. The first article, "Envelopes of Care," about caring for homeless families in Boston, appeared in April.

Janet M. Cromer is a freelance writer and regular contributor to On Call. She is a recipient of the 2008 Will Solimene Award for Excellence in Medical Communication. She received the award — her second — for her three-part series on medical humanities in Boston-area hospitals that appeared last year in On Call.